Disability Services

Application for
Services: Federal Law prohibits Viterbo Universityfrom making pre-admission inquiries
about disabilities. To provide assistance it is prudent for students with
disabilities to identify themselves in a timely manner. Information you provide
is voluntary and is kept confidential. To facilitate your learning experience at
Viterbo University, complete the following information and submit this
form along with proper disability documentation to Jane Eddy, disability services coordinator at 608-796-3194 or jleddy@viterbo.edu.

First name Last name

Address City State Zip

Student cell phone Student email

Date of birth Gender Ethnicity

Program
of study (intended academic major)

Do
you have a disability that limits one or more major life activities?

Yes

No

What is the nature of the
disability? (Check all that apply)

Deafness

Blindness

Mobility impairment

Traumatic brain injury

Autism Spectrum

Medical

Temporary

Hard of hearing

Visual impairment

Learning disability

Attention deficit disorder

Depression

Anxiety

Psychiatric

Other

If other, specify

What major life activity is involved? (Check all that apply)

Reading

Talking/speech

Math

Physical activities

Writing

Walking

Climbing stairs

Other

If other, specify

How
does this disability affect you in an educational setting?

Read and sign below:

It
is the student’s responsibility to make a disability known and to provide
proper documentation (including test results) from a licensed professional
describing diagnosis, limitations, and recommended academic adjustments
and/or auxiliary aids. Documentation should not be more than two years
old.

It
is the student’s responsibility to request services in advance each semester.

The
student understands that academic adjustments and/or auxiliary aids are
not automatically granted.

My signature below certifies that the information provided is
accurate and acknowledges that I am fully aware of my responsibilities as it relates
to my request for services. Failure to follow these guidelines may result in a
delay or interruption of services.